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Matbouei M, Samsami M, Soleimani M. Breast Cancer Survivors' Experiences of Acceptance Following Recurrence: A Qualitative Content Analysis. Cancer Nurs 2024; 47:E226-E235. [PMID: 36867010 DOI: 10.1097/ncc.0000000000001217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Breast cancer recurrence is a traumatic event for patients, and its treatment depends on the patient's ability to accept the circumstances. OBJECTIVE The aim of this study was to explore how patients experience breast cancer recurrence and go through a process of negotiating acceptance. METHODS This study explored the experiences of 16 patients with breast cancer recurrence regarding the acceptance of recurrence in a hospital in Tehran, Iran. Purposive sampling with maximum diversity was used. Data were collected through semistructured telephone interviews from November 2020 to November 2021 and analyzed using the qualitative content analysis. RESULTS Four themes emerged that described the process of accepting cancer recurrence: (1) response to recurrence (emotional reactions and loss of trust); (2) psychological preparedness (confirmation of medical diagnosis and acceptance of fate); (3) mobilizing supports (using spiritual capacities, utilizing supportive resources, and seeking relationships to promote knowledge); and (4) return to the path of treatment (rebuilding trust and continuation of treatment). CONCLUSIONS The acceptance of breast cancer recurrence is a process that begins with emotional reactions and ends with returning to the treatment path. The patient's psychological preparation, support systems, behavior of healthcare providers, and rebuilding trust are the determining factors in acceptance of recurrence. IMPLICATIONS FOR PRACTICE Nurses can compensate for the failures created in the primary treatment of breast cancer by spending time with patients and paying attention to their concerns, providing effective education, strengthening communication between patients with similar conditions and using the spiritual capacities of patients, and mobilizing the support of family and relatives.
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Affiliation(s)
- Mahsa Matbouei
- Author Affiliations: Student Research Committee, School of Nursing and Midwifery (Ms Matbouei), and Nursing Care Research Center (Dr Soleimani), Semnan University of Medical Sciences, Semnan; and Cancer Research Center, Shahid Beheshti University of Medical Science, Tehran, Iran (Dr Samsami)
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Vitko AS, Martin P, Zhang S, Johnston A, Ohsfeldt R, Zheng S, Liepa AM. Costs of breast cancer recurrence after initial treatment for HR+, HER2-, high-risk early breast cancer: estimates from SEER-Medicare linked data. J Med Econ 2024; 27:84-96. [PMID: 38059275 DOI: 10.1080/13696998.2023.2291266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE To assess the costs of treated recurrence and survival in elderly patients with early breast cancer (EBC) at high risk of recurrence using Surveillance Epidemiology and End Results (SEER) registry-Medicare linked claims data. METHODS This retrospective study included patients aged ≥65 years with hormone receptor-positive (HR+), human epidermal growth factor receptor 2 negative (HER2-), node-positive EBC at high risk of recurrence. Treated recurrences were defined based on treatment events/procedure codes from claims. Primary outcomes were monthly total extra costs and cumulative extra costs of treated recurrence relative to patients with non/untreated recurrence. Costs were calculated using a Kaplan-Meier sampling average estimator method and inflated to 2021 US$. Secondary outcomes included analysis by recurrence type and overall survival (OS) after recurrence. Subgroup analysis evaluated costs in patients with Medicare Part D coverage. RESULTS Among 3,081 eligible patients [mean (SD) age at diagnosis was 74.5 (7.1) years], the majority were females (97.4%) and white (87.8%). Treated recurrence was observed in 964 patients (31.3%). The monthly extra cost of treated recurrence was highest at the beginning of the first treated recurrence episode, with 6-year cumulative cost of $117,926. Six-year cumulative extra costs were higher for patients with distant recurrences ($168,656) than for patients with locoregional recurrences ($96,465). Median OS was 4.34 years for all treated recurrences, 1.92 years for distant recurrence, and 6.78 years for locoregional recurrence. Similar cumulative extra cost trends were observed in the subgroup with Part D coverage as in the overall population. LIMITATIONS This study utilizes claims data to identify treated recurrence. Due to age constraints of the dataset, results may not extrapolate to a younger population where EBC is commonly diagnosed. CONCLUSION EBC recurrence in this elderly population has substantial costs, particularly in patients with distant recurrences. Therapies that delay or prevent recurrence may reduce long-term costs significantly.
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Affiliation(s)
- Alexandra S Vitko
- Value, Evidence, and Outcomes (VEO) - Oncology, Eli Lilly and Company, Indianapolis, IN, USA
| | - Pam Martin
- Medical Decision Modeling Inc, Indianapolis, IN, USA
| | - Sheng Zhang
- Medical Decision Modeling Inc, Indianapolis, IN, USA
| | - Adam Johnston
- Medical Decision Modeling Inc, Indianapolis, IN, USA
| | - Robert Ohsfeldt
- Medical Decision Modeling Inc, Indianapolis, IN, USA
- Texas A&M University, College Station, TX, USA
| | - Shen Zheng
- TechData Service Company, King of Prussia, PA, USA
| | - Astra M Liepa
- Value, Evidence, and Outcomes (VEO) - Oncology, Eli Lilly and Company, Indianapolis, IN, USA
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Wang C, Guo M, Huang L, Sun S, Davis N. Factors Influencing Recurrence in Medial Breast Cancer Tumors After Skin Sparing Mastectomy and Immediate Breast Reconstruction. Clin Breast Cancer 2023; 23:876-881. [PMID: 37805386 DOI: 10.1016/j.clbc.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/08/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has been established as a safe option for curative-intent surgical resection. Prior studies have shown that medial location of the primary tumor is associated with increased risk of local recurrence. The purpose of this study is to determine the factors associated with recurrence and survival in individuals with breast cancers located in the inner quadrants (medial) who underwent SSM with IBR. METHODS A retrospective chart review was done on individuals with medial breast cancer who received SSM with IBR in British Columbia between 1980 and 2012. RESULTS Of 136 individuals with medial breast cancer undergoing SSM with IBR, 27.9% experienced local recurrence and 42.6% overall recurrence. Factors associated with recurrence were T-stage (44.8 vs. 22.4% with T2 disease, P = .02), transverse rectus abdominis muscle (TRAM) flap reconstruction (48.3 vs. 29.5%, P = .00395), prior breast surgery (87.9 vs. 63%, P = .002), and prior radiation therapy (74.1 vs. 38.5%, P < .0001). LR was associated with higher mortality (OR 2.78, 95% CI: 1.26-6.09). CONCLUSION For patients with medial tumors undergoing SSM with IBR, potential risk factors for recurrence are T-stage, TRAM flap reconstruction, prior breast surgery, and prior radiation therapy. Local recurrence is associated with poor survival.
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Affiliation(s)
- Christine Wang
- Department of Surgery, University of Calgary, Calgary, AB, Canada.
| | - Michael Guo
- Department of Surgery, University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
| | - Longlong Huang
- Department of Mathematics and Statistics, University of the Fraser Valley, Abbotsford, BC, Canada
| | - Shaun Sun
- Department of Mathematics and Statistics, University of the Fraser Valley, Abbotsford, BC, Canada
| | - Noelle Davis
- Department of Surgery, Surgical Oncology, University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada
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4
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Wärnberg F, Wadsten C, Karakatsanis A, Olofsson Bagge R, Holmberg E, Lindman H, Sawyer E, Vicini F, Mann GB, Karlsson P. Outcome of different radiotherapy strategies after breast conserving surgery in patients with ductal carcinoma in situ (DCIS). Acta Oncol 2023; 62:1045-1051. [PMID: 37571927 DOI: 10.1080/0284186x.2023.2245552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Adjuvant radiotherapy (RT) after breast-conserving surgery for DCIS lowers the relative local recurrence risk by half. To identify a low-risk group with the minimal benefit of RT could avoid side effects and spare costs. In this study, the outcome was compared for different RT-strategies using data from the randomized SweDCIS trial. MATERIAL AND METHODS Five strategies were compared in a Swedish setting: RT-to-none or all, RT to high-risk women defined by DCISionRT, modified Radiation Therapy Oncology Group (RTOG) 9804 criteria, and Swedish Guidelines. Ten-year recurrence risks and cost including adjuvant RT and local recurrence treatment cost were calculated. RESULTS The mean age at recurrence was 64.4 years (36-90) and the mean cost for treating a recurrence was $21,104. In the SweDCIS cohort (n = 504), 59 women developed DCIS, and 31 invasive recurrence. Ten-year absolute local recurrence risk (invasive and DCIS) according to different strategies varied between 18.6% (12.5-23.6%) and 7.8% (5.0-12.6%) for RT-to-none or to-all, with an additional cost of $2614 US dollars per women and $24,201 per prevented recurrence for RT-to-all. The risk differences between other strategies were not statistically significant, but the larger proportion receiving RT, the fewer recurrences. DCISionRT spared 48% from RT with 8.1% less recurrences compared to RT-to-none, and a cost of $10,534 per prevented recurrence with additional cost depending on the price of the test. RTOG 9804 spared 39% from RT, with 9.7% less recurrences, $9525 per prevented recurrence and Swedish Guidelines spared 13% from RT, with 10.0% less recurrences, and $21,521 per prevented recurrence. CONCLUSION It seems reasonable to omit RT in pre-specified low-risk groups with minimal effect on recurrence risk. Costs per prevented recurrence varied more than two-fold but which strategy that could be considered most cost-effective needs to be further evaluated, including the DCISionRT-test price.
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Affiliation(s)
- Fredrik Wärnberg
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Charlotta Wadsten
- Department of Surgery, Sundsvall Hospital, Umeå University, Umeå, Sweden
| | | | - Roger Olofsson Bagge
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Henrik Lindman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Elinor Sawyer
- Guys Cancer centre, Kings College London, London, UK
| | - Frank Vicini
- Regional Oncologic Centre, NRG, Oncology, and 21st Century Oncology, Pontiac, MI, USA
| | - G Bruce Mann
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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5
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Haas NB, Song Y, Willemann Rogerio J, Zhang S, Carley C, Zhu J, Bhattacharya R, Signorovitch J, Sundaram M. Disease-free survival as a predictor of overall survival in localized renal cell carcinoma following initial nephrectomy: A retrospective analysis of Surveillance, Epidemiology and End Results-Medicare datac. Int J Urol 2023; 30:272-279. [PMID: 36788716 DOI: 10.1111/iju.15104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/10/2022] [Indexed: 02/16/2023]
Abstract
OBJECTIVES This study aimed to assess whether disease-free survival (DFS) may serve as a predictor for long-term survival among patients with intermediate-high risk or high risk renal cell carcinoma (RCC) post-nephrectomy when overall survival (OS) is unavailable. METHODS The Surveillance, Epidemiology and End Results-Medicare database (2007-2016) was used to identify patients with non-metastatic intermediate-high risk and high risk RCC post-nephrectomy. Landmark analysis and Kendall's τ were used to evaluate the correlation between DFS and OS. Multivariable regression models were used to quantify the incremental OS post-nephrectomy associated with increased time to recurrence among patients with recurrence, adjusting for baseline covariates. RESULTS A total of 643 patients were analyzed; mean age of 75 years; >95% of patients had intermediate-high risk RCC at diagnosis; 269 patients had recurrence post-nephrectomy. For patients with versus without recurrence at the landmark points of 1, 3, and 5 years post-nephrectomy, the 5-year OS were 37.0% versus 70.1%, 42.3% versus 72.8%, and 53.2% versus 78.6%, respectively. The Kendall's τ between DFS and OS post-nephrectomy was 0.70 (95% CI: 0.65, 0.74; p < 0.001). After adjusting for baseline covariates, patients with one additional year of time to recurrence were associated with 0.73 years longer OS post-nephrectomy (95% CI: 0.40, 1.05; p < 0.001). CONCLUSION The significant positive association of DFS and OS among patients with intermediate-high risk and high risk RCC post-nephrectomy from this study supports the use of DFS as a potential predictor of OS for these patients when OS data are immature.
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Affiliation(s)
- Naomi B Haas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Song
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | - Su Zhang
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | - JingJing Zhu
- Analysis Group, Inc., Boston, Massachusetts, USA
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6
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Sundaram M, Song Y, Rogerio JW, Zhang S, Bhattacharya R, Adejoro O, Carley C, Zhu JJ, Signorovitch J, Haas NB. Clinical and economic burdens of recurrence following nephrectomy for intermediate high- or high-risk renal cell carcinoma: A retrospective analysis of Surveillance, Epidemiology, and End Results–Medicare data. J Manag Care Spec Pharm 2022; 28:1149-1160. [DOI: 10.18553/jmcp.2022.22133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Murali Sundaram
- Merck Sharp & Dohme LLC., a subsidiary of Merck & Co., Inc., Rahway, NJ
| | - Yan Song
- Analysis Group, Inc., Boston, MA
| | | | - Su Zhang
- Analysis Group, Inc., Boston, MA
| | | | - Oluwakayode Adejoro
- Merck Sharp & Dohme LLC., a subsidiary of Merck & Co., Inc., Rahway, NJ
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA
| | | | - Jing Jing Zhu
- Analysis Group, Inc., Boston, MA
- Student at School of Medicine, Washington University, St Louis, MO
| | | | - Naomi B Haas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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NMR-based metabolomic analysis identifies RON-DEK-β-catenin dependent metabolic pathways and a gene signature that stratifies breast cancer patient survival. PLoS One 2022; 17:e0274128. [PMID: 36067206 PMCID: PMC9447910 DOI: 10.1371/journal.pone.0274128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/22/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Advances in detection techniques and treatment have increased the diagnosis of breast cancer at early stages; however, recurrence occurs in all breast cancer subtypes, and both recurrent and de novo metastasis are typically treatment resistant. A growing body of evidence supports the notion that metabolic plasticity drives cancer recurrence. RON and DEK are proteins that promote cancer metastasis and synergize mechanistically to activate β-catenin, but the metabolic consequences are unknown. METHODS To ascertain RON-DEK-β-catenin dependent metabolic pathways, we utilized an NMR-based metabolomics approach to determine steady state levels of metabolites. We also interrogated altered metabolic pathway gene expression for prognostic capacity in breast cancer patient relapse-free and distant metastasis-free survival and discover a metabolic signature that is likely associated with recurrence. RESULTS RON-DEK-β-catenin loss showed a consistent metabolite regulation of succinate and phosphocreatine. Consistent metabolite alterations between RON and DEK loss (but not β-catenin) were found in media glucose consumption, lactate secretion, acetate secretion, and intracellular glutamine and glutathione levels. Consistent metabolite alterations between RON and β-catenin loss (and not DEK) were found only in intracellular lactate levels. Further pathway hits include β-catenin include glycolysis, glycosylation, TCA cycle/anaplerosis, NAD+ production, and creatine dynamics. Genes in these pathways epistatic to RON-DEK-β-catenin were used to define a gene signature that prognosticates breast cancer patient survival and response to chemotherapy. CONCLUSIONS The RON-DEK-β-catenin axis regulates the numerous metabolic pathways with significant associations to breast cancer patient outcomes.
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Ali AA, Tawk R, Xiao H, Semykina A, Montero AJ, Moussa RK, Popoola O, Diaby V. Comparative cost-effectiveness of radiotherapy among older women with hormone receptor positive early-stage breast cancer. Expert Rev Pharmacoecon Outcomes Res 2022; 22:735-741. [PMID: 35189767 PMCID: PMC10791147 DOI: 10.1080/14737167.2022.2044309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim was to examine the real-world cost-effectiveness of breast-conserving surgery (BCS) plus hormonal therapy with radiotherapy, compared to hormonal therapy alone among women 66 and older with hormone receptor positive early-stage breast cancer in the United States (US). METHODS This study was conducted from a U.S. Centers for Medicare and Medicaid Services perspective and an eight-year time horizon. Both costs (2020 US$) and health utilities (quality-adjusted life years, QALYs) were obtained from retrospective studies using the SEER linked with Medicare and Medicare Health Outcomes Survey, respectively. The incremental cost-effectiveness ratio (ICER) of the addition of radiotherapy to hormonal therapy versus hormonal therapy alone after BCS was estimated by an unbiased doubly robust estimator. Sensitivity analyses were conducted through bootstrapping to estimate credible intervals. RESULTS The addition of radiotherapy to hormonal therapy after BCS yielded the highest clinical benefits (2.66 QALYs) and costs ($19,424.27) compared to its hormonal therapy alone after BCS (0.77 QALYS; $2,028.58). The ICER was estimated to be $9,174.94/QALY. Sensitivity analyses did not change the direction of the findings. CONCLUSIONS The results implicated that the combination of radiotherapy and hormonal therapy is cost-effective in the US.
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Affiliation(s)
- Askal Ayalew Ali
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Rima Tawk
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Hong Xiao
- Solid tumor, Bristol Myers Squibb, Lawrenceville, NJ USA
| | | | - Alberto J. Montero
- Breast Cancer Program, Uh Seidman Cancer Center, CWRU School of Medicine
| | - Richard K. Moussa
- Ecole Nationale Supérieure de Statistiques Et d’Economie Appliquée (ENSEA), Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Olayiwola Popoola
- Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Vakaramoko Diaby
- Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, Hpnp 3337, University of Florida, Gainesville, FL, USA
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9
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Hrebinko KA, Bryce CL, Downs-Canner S, Diego EJ, Myers SP. Cost-effectiveness of Choosing Wisely guidelines for axillary observation in women older than age 70 years with hormone receptor-positive, clinically node-negative, operable breast tumors. Cancer 2022; 128:2258-2268. [PMID: 35389517 PMCID: PMC10964149 DOI: 10.1002/cncr.34207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/01/2022] [Accepted: 02/21/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Society for Surgical Oncology's Choosing Wisely guidelines recommend against sentinel lymph node biopsy (SLNB) in favor of observation in this population. Recent analyses reveal that this has not been widely adopted. The purpose of this cost-effectiveness analysis is to compare the costs and benefits associated with observation or SLNB in women >70 years old with hormone receptor-positive, clinically node-negative, operable breast cancer. METHODS A decision tree with Markov modeling was created to compare treatment strategies using long-term follow-up data from clinical trials in this population. Costs were estimated from published literature and publicly available databases. Breast cancer-specific health-state utilities were derived from the literature and expert opinion. One-way, 2-way, and probabilistic sensitivity analyses were conducted. A structural sensitivity analysis was performed to assess the effect of functional status and anxiety from nonevaluation of the axilla on cost-effectiveness. Costs and benefits, measured in life-years (LYs) and quality-adjusted life-years (QALYs), were tabulated across 10, 15, and 20 years and compared using incremental cost-effectiveness ratios (ICERs). RESULTS SLNB is not cost-effective from the payer or societal perspectives with ICERs of $138,374/LY and $131,900/LY, respectively. When QALYs were considered, SLNB provided fewer QALYs (SLNB, 10.33 QALYs; observation, 10.53 QALYs) at a higher cost (SLNB, $15,845; observation, $4020). Structural sensitivity analysis revealed that SLNB was cost-effective in certain patients with significant anxiety related to axillary observation (ICER, $39,417/QALY). CONCLUSIONS Routine SLNB in this population is not cost-effective. The cost-effectiveness of SLNB, however, is dependent on individual patient factors, including functional status as well as patient preference.
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Affiliation(s)
- Katherine A Hrebinko
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cindy L Bryce
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | | | - Emilia J Diego
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sara P Myers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Caswell-Jin JL, Callahan A, Purington N, Han SS, Itakura H, John EM, Blayney DW, Sledge GW, Shah NH, Kurian AW. Treatment and Monitoring Variability in US Metastatic Breast Cancer Care. JCO Clin Cancer Inform 2021; 5:600-614. [PMID: 34043432 DOI: 10.1200/cci.21.00031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Treatment and monitoring options for patients with metastatic breast cancer (MBC) are increasing, but little is known about variability in care. We sought to improve understanding of MBC care and its correlates by analyzing real-world claims data using a search engine with a novel query language to enable temporal electronic phenotyping. METHODS Using the Advanced Cohort Engine, we identified 6,180 women who met criteria for having estrogen receptor-positive, human epidermal growth factor receptor 2-negative MBC from IBM MarketScan US insurance claims (2007-2014). We characterized treatment, monitoring, and hospice usage, along with clinical and nonclinical factors affecting care. RESULTS We observed wide variability in treatment modality and monitoring across patients and geography. Most women received first-recorded therapy with endocrine (67%) versus chemotherapy, underwent more computed tomography (CT) (76%) than positron emission tomography-CT, and were monitored using tumor markers (58%). Nearly half (46%) met criteria for aggressive disease, which were associated with receiving chemotherapy first, monitoring primarily with CT, and more frequent imaging. Older age was associated with endocrine therapy first, less frequent imaging, and less use of tumor markers. After controlling for clinical factors, care strategies varied significantly by nonclinical factors (median regional income with first-recorded therapy and imaging type, geographic region with these and with imaging frequency and use of tumor markers; P < .0001). CONCLUSION Variability in US MBC care is explained by patient and disease factors and by nonclinical factors such as geographic region, suggesting that treatment decisions are influenced by local practice patterns and/or resources. A search engine designed to express complex electronic phenotypes from longitudinal patient records enables the identification of variability in patient care, helping to define disparities and areas for improvement.
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Affiliation(s)
| | - Alison Callahan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Natasha Purington
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Summer S Han
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Haruka Itakura
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Esther M John
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Douglas W Blayney
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - George W Sledge
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nigam H Shah
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Allison W Kurian
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
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11
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Yang J, Qi SN, Fang H, Song YW, Jin J, Liu YP, Wang WH, Yang Y, Tang Y, Ren H, Chen B, Lu NN, Tang Y, Li N, Jing H, Wang SL, Li YX. Cost-effectiveness of postmastectomy hypofractionated radiation therapy vs conventional fractionated radiation therapy for high-risk breast cancer. Breast 2021; 58:72-79. [PMID: 33933925 PMCID: PMC8105681 DOI: 10.1016/j.breast.2021.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background The phase 3 NCT00793962 trial demonstrated that postmastectomy hypofractionated radiation therapy (HFRT) was noninferior to conventional fractionated radiation therapy (CFRT) in patients with high-risk breast cancer. This study assessed the cost-effectiveness of postmastectomy HFRT vs CFRT based on the NCT00793962 trial. Methods A Markov model was adopted to synthesize the medical costs and health benefits of patients with high-risk breast cancer based on data from the NCT00793962 trial. Main outcomes were discounted lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). We employed a time-dependent horizon from Chinese, French and USA payer perspectives. Model robustness was evaluated with one-way and probabilistic sensitivity analyses. Results Patients receiving CFRT versus HFRT gained an incremental 0.0163 QALYs, 0.0118 QALYs and 0.0028 QALYs; meanwhile an incremental cost of $2351.92, $4978.34 and $8812.70 from Chinese, French and USA payer perspectives, respectively. Thus CFRT versus HFRT yielded an ICER of $144,281.47, $420,636.10 and $3,187,955.76 per QALY from Chinese, French and USA payer perspectives, respectively. HFRT could maintain a trend of >50% probabilities of cost-effectiveness below a willingness-to-pay (WTP) of $178,882.00 in China, while HFRT was dominant relative to CFRT, regardless of the WTP values in France and the USA. Sensitivity analyses indicated that the ICERs were most sensitive to the parameters of overall survival after radiotherapy. Conclusions Postmastectomy HFRT could be used as a cost-effective substitute for CFRT in patients with high-risk breast cancer and should be considered in appropriately selected patients. HFRT is a cost-effective substitute for CFRT for women with high-risk breast cancer. The incremental cost-effectiveness ratio varied in a time-dependent manner and increased with the time horizon. Overall survival were the most influential parameter on the incremental cost-effectiveness ratio.
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Affiliation(s)
- Jing Yang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shu-Nan Qi
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hui Fang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yong-Wen Song
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jing Jin
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yue-Ping Liu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Wei-Hu Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yong Yang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yu Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hua Ren
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Bo Chen
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Ning-Ning Lu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yuan Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Ning Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hao Jing
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shu-Lian Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China.
| | - Ye-Xiong Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China.
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Jiang Y, Cao W, Luo Y, Xu J, Li Y, Li J. Post-Surgery Subcutaneous Seeding of Laryngeal Squamous Cell Carcinoma: A Rare Case. Case Rep Oncol 2021; 14:568-572. [PMID: 33976635 PMCID: PMC8077469 DOI: 10.1159/000510361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/02/2022] Open
Abstract
Laryngeal squamous cell carcinoma (LSCC) is the most common malignant head and neck cancer, with a 40% recurrence rate in the first 3 years after radical treatment. Recurrence of LSCC mostly comprises lymphogenous metastasis, hematogenic metastasis, and locoregional recurrence, while LSCC seeding is rarest: there are only 4 cases reported in PubMed, and none of them is one of subcutaneous seeding. We report a case with post-surgery subcutaneous seeding of LSCC. The final biopsy demonstrated that the subcutaneous seeding of the LSCC was 2 cm away from the primary lesion, with no recurrent foci observed in the larynx and tracheostoma and little relation to the primary lesion. Thus, we drew the conclusion that LSCC surgeries should stick to the principle of the non-tumor technique to prevent subcutaneous seeding.
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Affiliation(s)
- Yongquan Jiang
- Department of Otolaryngology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wanxin Cao
- Department of Otolaryngology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuanbo Luo
- School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ji Xu
- Department of Otolaryngology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ying Li
- Department of Otolaryngology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jiping Li
- Department of Otolaryngology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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13
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Xie Y, Guo B, Zhang R. Cost-effectiveness analysis of radiotherapy techniques for whole breast irradiation. PLoS One 2021; 16:e0248220. [PMID: 33684139 PMCID: PMC7939353 DOI: 10.1371/journal.pone.0248220] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background The current standard of care (SOC) for whole breast radiotherapy (WBRT) in the US is conventional tangential photon fields. Advanced WBRT techniques may provide similar tumor control and better normal tissue sparing, but it is controversial whether the medical benefits of an advanced technology are significant enough to justify its higher cost. Objective To analyze the cost-effectiveness of six advanced WBRT techniques compared with SOC. Methods We developed a Markov model to simulate health states for one cohort of women (65-year-old) with early-stage breast cancer over 15 years after WBRT. The cost effectiveness analyses of field-in-field (FIF), hybrid intensity modulated radiotherapy (IMRT), full IMRT, standard volumetric modulated arc therapy (STD-VMAT), multiple arc VMAT (MA-VMAT), non-coplanar VMAT (NC-VMAT) compared with SOC were performed with both tumor control and radiogenic side effects considered. Transition probabilities and utilities for each health state were obtained from literature. Costs incurred by payers were adopted from literature and Medicare data. Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER) were calculated. One-way sensitivity analyses and probabilistic sensitivity analyses (PSA) were performed to evaluate the impact of uncertainties on the final results. Results FIF has the lowest ICER value of 1,511 $/QALY. The one-way analyses show that the cost-effectiveness of advanced WBRT techniques is most sensitive to the probability of developing contralateral breast cancer. PSAs show that SOC is more cost effective than almost all advanced WBRT techniques at a willingness-to-pay (WTP) threshold of 50,000 $/QALY, while FIF, hybrid IMRT and MA-VMAT are more cost-effective than SOC with a probability of 59.2%, 72.3% and 72.6% at a WTP threshold of 100,000 $/QALY, respectively. Conclusions FIF might be the most cost-effective option for WBRT patients at a WTP threshold of 50,000 $/QALY, while hybrid IMRT and MA-VMAT might be the most cost-effective options at a WTP threshold of 100,000 $/QALY.
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Affiliation(s)
- Yibo Xie
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America
| | - Beibei Guo
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, Louisiana, United States of America
| | - Rui Zhang
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, United States of America
- Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, United States of America
- * E-mail:
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14
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Xie Y, Guo B, Zhang R. Cost-effectiveness analysis of advanced radiotherapy techniques for post-mastectomy breast cancer patients. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:26. [PMID: 32774176 PMCID: PMC7398314 DOI: 10.1186/s12962-020-00222-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/30/2020] [Indexed: 11/21/2022] Open
Abstract
Background Prior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT). Methods Using a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). Results For the patient cohort, STD-VMAT has an ICER of $32,617/QALY relative to SOC; TOMO is dominated by STD-VMAT; IMRT has an ICER of $19,081/QALY relative to STD-VMAT; NC-VMAT, MA-VMAT, MIXED are dominated by IMRT; IMPT has an ICER of $151,741/QALY relative to IMRT. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of $100,000/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY. Conclusion Advanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of $100,000/QALY, and IMRT might be a cost-effective option for PMRT patients.
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Affiliation(s)
- Yibo Xie
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA USA
| | - Beibei Guo
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, LA USA
| | - Rui Zhang
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA USA.,Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, LA USA
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15
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McEvoy AM, Poplack S, Nickel K, Olsen MA, Ademuyiwa F, Zoberi I, Odom E, Yu J, Chang SH, Gillanders WE. Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound. Breast Cancer Res Treat 2020; 183:251-262. [PMID: 32651755 DOI: 10.1007/s10549-020-05768-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS. METHODS We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR+/HER2- breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed. RESULTS Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients. CONCLUSION Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR+/HER2- breast cancer and negative AUS.
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Affiliation(s)
- Aubriana M McEvoy
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Steven Poplack
- Department of Diagnostic Radiology, Section of Breast Imaging, Washington, University St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, St. Louis, MO, USA
| | - Katelin Nickel
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
| | - Margaret A Olsen
- Siteman Cancer Center, St. Louis, MO, USA
- Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - Foluso Ademuyiwa
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Medical Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Imran Zoberi
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Radiation Oncology, Washington, University St. Louis, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic Surgery, Washington, University St. Louis, St. Louis, MO, USA
| | - Jennifer Yu
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA
| | - Su-Hsin Chang
- Siteman Cancer Center, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA
| | - William E Gillanders
- Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA.
- Siteman Cancer Center, St. Louis, MO, USA.
- Department of Surgery, Washington University School of Medicine, Campus Box 8109, 4590 Children's Place, Suite 9600, St. Louis, MO, 63110, USA.
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A case-based ensemble learning system for explainable breast cancer recurrence prediction. Artif Intell Med 2020; 107:101858. [DOI: 10.1016/j.artmed.2020.101858] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023]
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17
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Uno H, Ritzwoller DP, Cronin AM, Carroll NM, Hornbrook MC, Hassett MJ. Determining the Time of Cancer Recurrence Using Claims or Electronic Medical Record Data. JCO Clin Cancer Inform 2019; 2:1-10. [PMID: 30652573 DOI: 10.1200/cci.17.00163] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Data from claims and electronic medical records (EMRs) are frequently used to identify clinical events (eg, cancer diagnosis, stroke). However, accurately determining the time of clinical events can be challenging, and the methods used to generate time estimates are underdeveloped. We sought to develop an approach to determine the time of a clinical event-cancer recurrence-using high-dimensional longitudinal structured data. METHODS Manual chart abstraction provided information regarding the actual time of cancer recurrence. These data were linked to claims from Medicare or structured EMR data from the Cancer Research Network, which were used to determine time of recurrence for patients with lung or colorectal cancer. We analyzed the longitudinal profile of codes that could help determine the time of recurrence, adjusted for systematic differences between code dates and recurrence dates, and integrated time estimates from different codes to empirically derive an optimal algorithm. RESULTS We identified twelve code groups that could help determine the time of recurrence. Using claims data for patients with lung cancer, the optimal algorithm consisted of three code groups and provided an average prediction error of 4.8 months. Using EMR data or applying this approach to patients with colorectal cancer yielded similar results. CONCLUSION Time estimates were improved by selecting codes not necessarily the same as those used to identify recurrence, combining time estimates from multiple code groups, and adjusting for systematic bias between code dates and recurrence dates. Improving the accuracy of time estimates for clinical events can facilitate research, quality measurement, and process improvement.
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Affiliation(s)
- Hajime Uno
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
| | - Debra P Ritzwoller
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
| | - Angel M Cronin
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
| | - Nikki M Carroll
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
| | - Mark C Hornbrook
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
| | - Michael J Hassett
- Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR
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18
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Hassett MJ, Banegas M, Uno H, Weng S, Cronin AM, O'Keeffe Rosetti M, Carroll NM, Hornbrook MC, Ritzwoller DP. Spending for Advanced Cancer Diagnoses: Comparing Recurrent Versus De Novo Stage IV Disease. J Oncol Pract 2019; 15:e616-e627. [PMID: 31107629 DOI: 10.1200/jop.19.00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending. METHODS Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors. RESULTS We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all P < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all P < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]). CONCLUSION Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.
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Affiliation(s)
- Michael J Hassett
- 1 Dana-Farber Cancer Institute, Boston, MA.,2 Harvard Medical School, Boston, MA
| | | | - Hajime Uno
- 1 Dana-Farber Cancer Institute, Boston, MA.,2 Harvard Medical School, Boston, MA
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Rocque GB, Kandhare PG, Williams CP, Nakhmani A, Azuero A, Burkard ME, Forero A, Bhatia S, Kenzik KM. Visualization of Sequential Treatments in Metastatic Breast Cancer. JCO Clin Cancer Inform 2019; 3:1-8. [PMID: 30840488 DOI: 10.1200/cci.18.00095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Treatment sequencing of metastatic breast cancer (MBC) is heterogeneous. The primary objective of this study was to develop a visualization technique to understand population-level treatment sequencing for MBC. Secondary outcomes were to describe the heterogeneity of MBC treatment sequencing, as measured by the proportion of patients with a rare sequence, and to generate hypotheses about the impact of sequencing on overall survival. METHODS This retrospective review evaluated treatment sequencing for patients with MBC in the SEER-Medicare database. Patients with either de novo MBC or International Classification of Diseases, Ninth Revision, diagnosis codes for secondary metastasis (197.XX-198.XX) on two separate dates, excluding breast (198.81, 198.82, 198.2) and lymph nodes (196.XX), were included. Complete Medicare Parts A, B, and D coverage was required. A treatment sequence that fewer than 11 patients received was considered rare. A graphic was created with each nonrare treatment-sequence grouping on the y-axis and time on the x-axis. Bars representing time on hormonal therapy, chemotherapy, human epidermal growth factor receptor 2-targeted therapy, and other targeted therapies were color coded. Kaplan-Meier-like curves were overlaid on treatment maps, using estimated median survival for each sequence. RESULTS Of 6,639 patients with MBC, 56% received a treatment sequence that fewer than 11 other patients received, with 2,985 other unique, rare sequences were identified. Sequence visualization demonstrated differential survival, with longer median survival for those initially receiving hormonal therapy. The median time receiving initial treatment was similar for patients receiving first-line chemotherapy. CONCLUSION Treatment-sequence visualization can enhance the capacity to effectively conceptualize treatment patterns and patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
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Satram-Hoang S, Bajaj P, Stein A, Cortazar P, Momin F, Reyes C. Treatment Patterns and Mortality Risk among Elderly Patients with Metastatic Triple Negative Breast Cancer in the United States: An Observational Cohort Study Using SEER-Medicare Data. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/jct.2019.102009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Ritzwoller DP, Fishman PA, Banegas MP, Carroll NM, O'Keeffe‐Rosetti M, Cronin AM, Uno H, Hornbrook MC, Hassett MJ. Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis. Health Serv Res 2018; 53:5106-5128. [PMID: 30043542 PMCID: PMC6232408 DOI: 10.1111/1475-6773.13014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients. DATA SOURCES/STUDY SETTING Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington. STUDY DESIGN We identified patients aged ≥21 with de novo or recurrent breast (nde novo = 352; nrecurrent = 765), colorectal (nde novo = 1,072; nrecurrent = 542), and lung (nde novo = 4,041; nrecurrent = 340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12 months preceding, month of, and 12 months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity. PRINCIPAL FINDINGS In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65. CONCLUSIONS Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.
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Affiliation(s)
| | - Paul A. Fishman
- Department of Health ServicesUniversity of WashingtonSeattleWA
- Kaiser Permanente Washington Health Research InstituteSeattleWA
| | | | | | | | | | - Hajime Uno
- Dana‐Farber Cancer InstituteBostonMA
- Harvard Medical SchoolBostonMA
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22
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Malhotra J, Rotter D, Jabbour SK, Aisner J, Lin Y, Manne S, Demissie K. Receipt of recommended surveillance with imaging in elderly survivors of early stage non-small cell lung cancer. Lung Cancer 2018; 125:205-211. [PMID: 30429021 PMCID: PMC10865993 DOI: 10.1016/j.lungcan.2018.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 09/28/2018] [Accepted: 09/30/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Early-stage lung cancer survivorsremain at high risk for recurrence or second cancers. We measured the rates and determinants of regular surveillance imaging in early-stage non-small cell lung cancer (NSCLC) survivors. METHODS Patients (diagnosed 2001-2011) with resected stage I and II NSCLC were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked database. Patients were censored at recurrence/second cancer diagnosis, loss to follow-up or death. Receipt of a scan during the surveillance periods of 7-18, 19-30, 31-42 and 43-60 months from date of surgery was assessed. RESULTS Of 10,680 survivors assessed during the 18-month surveillance period, 71% received imaging in first 18 months. Only 56% and 43% continued to receive regular imaging by 30-month and 60-month of follow-up, respectively. Survivors were less likely to receive imaging if they were older, black, unmarried, received no adjuvant therapy, had stage I disease (vs. stage II) or were diagnosed before 2006. In adjusted analysis, survivors who received recommended imaging up to 18 months from surgery experienced better survival compared to survivors who did not (HR 0.92; 95% CI 0.85-0.99). Survival benefit was also observed in survivors who underwent regular imaging up to 5 years from surgery (HR 0.68; 95% CI 0.60-0.78). CONCLUSIONS More than half the lung cancer survivors received less than the recommended long-term surveillance imaging. Long-term adherence to surveillance is associated with improved survival. Our study provides evidence to support the current clinical guidelines for surveillance for lung cancer survivors that are primarily consensus-based at present.
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Affiliation(s)
- Jyoti Malhotra
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States.
| | - David Rotter
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Joseph Aisner
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Yong Lin
- Department of Epidemiology, Rutgers School of Public Health, Piscataway, NJ, United States
| | - Sharon Manne
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Kitaw Demissie
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States; Department of Epidemiology, Rutgers School of Public Health, Piscataway, NJ, United States
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Rocque GB, Williams CP, Kenzik KM, Jackson BE, Azuero A, Halilova KI, Ingram SA, Pisu M, Forero A, Bhatia S. Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer 2018; 124:4231-4240. [DOI: 10.1002/cncr.31694] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Gabrielle B. Rocque
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Courtney P. Williams
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Kelly M. Kenzik
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Andres Azuero
- School of Nursing; University of Alabama at Birmingham; Birmingham Alabama
| | - Karina I. Halilova
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Stacey A. Ingram
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Maria Pisu
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Andres Forero
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Smita Bhatia
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
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Williams CP, Kenzik KM, Azuero A, Williams GR, Pisu M, Halilova KI, Ingram SA, Yagnik SK, Forero A, Bhatia S, Rocque GB. Impact of Guideline-Discordant Treatment on Cost and Health Care Utilization in Older Adults with Early-Stage Breast Cancer. Oncologist 2018; 24:31-37. [PMID: 30120157 DOI: 10.1634/theoncologist.2018-0076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND National Comprehensive Cancer Network (NCCN) guideline-based treatment is a marker of high-quality care. The impact of guideline discordance on cost and health care utilization is unclear. MATERIALS AND METHODS This retrospective cohort study of Medicare claims data from 2012 to 2015 included women age ≥65 with stage I-III breast cancer receiving care within the University of Alabama at Birmingham Cancer Community Network. Concordance with NCCN guidelines was assessed for treatment regimens. Costs to Medicare and health care utilization were identified from start of cancer treatment until death or available follow-up. Adjusted monthly cost and utilization rates were estimated using linear mixed effect and generalized linear models. RESULTS Of 1,177 patients, 16% received guideline-discordant treatment, which was associated with nonwhite race, estrogen receptor/progesterone receptor negative, human epidermal growth receptor 2 (HER2) positive, and later-stage cancer. Discordant therapy was primarily related to reduced-intensity treatments (single-agent chemotherapy, HER2-targeted therapy without chemotherapy, bevacizumab without chemotherapy, platinum combinations without anthracyclines). In adjusted models, average monthly costs for guideline-discordant patients were $936 higher compared with concordant (95% confidence limits $611, $1,260). For guideline-discordant patients, adjusted rates of emergency department visits and hospitalizations per thousand observations were 25% higher (49.9 vs. 39.9) and 19% higher (24.0 vs. 20.1) per month than concordant patients, respectively. CONCLUSION One in six patients with early-stage breast cancer received guideline-discordant care, predominantly related to undertreatment, which was associated with higher costs and rates of health care utilization. Additional randomized trials are needed to test lower-toxicity regimens and guide clinicians in treatment for older breast cancer patients. IMPLICATIONS FOR PRACTICE Previous studies lack details about types of deviations from chemotherapy guidelines that occur in older early-stage breast cancer patients. Understanding the patterns of guideline discordance and its impact on patient outcomes will be particularly important for these patients. This study found 16% received guideline-discordant care, predominantly related to reduced intensity treatment and associated with higher costs and rates of health care utilization. Increasing older adult participation in clinical trials should be a priority in order to fill the knowledge gap about how to treat older, less fit patients with breast cancer.
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Affiliation(s)
- Courtney P Williams
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly M Kenzik
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andres Azuero
- School of Nursing, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Grant R Williams
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria Pisu
- Division of Preventive Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karina I Halilova
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacey A Ingram
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Andres Forero
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, Alabama, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, Alabama, USA
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Manjelievskaia J, Brown D, Shao S, Hofmann K, Shriver CD, Zhu K. Breast Cancer Treatment and Survival Among Department of Defense Beneficiaries: An Analysis by Benefit Type and Care Source. Mil Med 2018; 183:e186-e195. [PMID: 29365174 DOI: 10.1093/milmed/usx031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 10/20/2017] [Indexed: 11/13/2022] Open
Abstract
Background Use of treatment for breast cancer is dependent on the patient's cancer characteristics and willingness to undergo treatment and provider treatment recommendations. Receipt of breast cancer treatment varies by insurance status and type. It is not clear whether different benefit types and care sources differ in breast cancer treatment and outcomes among Department of Defense beneficiaries. Methods The objectives of this study are to assess whether receipt of breast cancer treatment varied by benefit type (TRICARE Prime vs non-Prime) or care source (direct care, purchased care, and both) and to examine whether survival and recurrence differed by benefit type and/or care source among female Department of Defense beneficiaries with the disease. Study subjects were women aged 40-64 yr, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess the likelihood of receiving treatment by benefit type or care source. Multivariable Cox proportional hazard models were used to investigate differences in survival and recurrence by benefit type or care source. Findings A total of 2,668 women were included in this study. Those with Prime were more likely to have chemotherapy, radiation, hormone therapy, breast-conserving surgery, surveillance mammography, and recurrence than women with non-Prime. Survival was high, with 94.86% of those with Prime and 92.58% with non-Prime alive at the end of the study period. Women aged 50-59 yr with non-Prime benefit type had better survival than women with Prime of the same age. No survival differences were seen by care source. In regard to recurrence, women aged 60-64 yr with TRICARE Prime were more likely to have recurrent breast cancer than women with non-Prime. Additionally, women aged 50-59 yr who used purchased care were less likely to have a recurrence than women who used direct care only. Discussion/Impact/Recommendations To our knowledge, this is the first study to examine breast cancer treatment and survival by care source and benefit type in the Military Health System. In this equal access health care system, no differences in treatment, except mastectomy, by benefit type, were observed. There were no overall differences in survival, although patients with non-Prime tended to have better survival in the age group of 50-59 yr. In regard to care source, women who utilized mostly purchased care or utilized both direct and purchased care were more likely to receive certain types of treatment, such as chemotherapy and radiation, as compared with women who used direct care only. However, survival did not differ between different care sources. Future research is warranted to further investigate variations in breast cancer treatment and its survival gains by benefit type and care source among Department of Defense beneficiaries.
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Affiliation(s)
- Janna Manjelievskaia
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville,MD 20852
| | - Derek Brown
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville,MD 20852
| | - Stephanie Shao
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD 20852.,Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Keith Hofmann
- Kennell and Associates, Inc., 3130 Fairview Park Drive, Suite 450, Falls Church,VA 22042
| | - Craig D Shriver
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD 20852.,Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Kangmin Zhu
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD 20852.,Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814
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The continuum of breast cancer care and outcomes in the U.S. Military Health System: an analysis by benefit type and care source. J Cancer Surviv 2018; 12:407-416. [PMID: 29455447 DOI: 10.1007/s11764-018-0680-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/07/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE This study investigates transition rates between breast cancer diagnosis, recurrence, and death by insurance benefit type and care source in U.S. Military Health System (MHS). METHODS The MHS data repository and central cancer registry linked data were used to identify women aged 40-64 with histologically confirmed breast cancer between 2003 and 2007. Three-state continuous time Markov models were used to estimate transition rates and transition rate ratios (TRRs) by TRICARE benefit type (Prime or non-Prime) and care source (direct, purchased, or both), adjusted for demographic, tumor, and treatment variables. RESULTS Analyses included 2668 women with transitions from diagnosis to recurrence (n = 832), recurrence to death (n = 79), and diagnosis to death without recurrence (n = 91). Compared to women with Prime within each care source, women with non-Prime using both care sources had higher transition rates (TRR 1.47, 95% CI 1.03, 2.10). Compared to those using direct care within each benefit type, women utilizing both care sources with non-Prime had higher transition rates (TRR 1.86, 95% CI 1.11, 3.13), while women with Prime utilizing purchased care had lower transition rates (TRR 0.82, 95% CI 0.68, 0.98). CONCLUSIONS In the MHS, women with non-Prime benefit plans compared to Prime had higher transition rates along the breast cancer continuum among both care source users. Purchased care users had lower transition rates than direct care users among Prime beneficiaries. IMPLICATIONS FOR CANCER SURVIVORS Benefit plan and care source may be associated with breast cancer progression. Further research is needed to demonstrate differences in survivorship.
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Chandler Y, Schechter CB, Jayasekera J, Near A, O’Neill SC, Isaacs C, Phelps CE, Ray GT, Lieu TA, Ramsey S, Mandelblatt JS. Cost Effectiveness of Gene Expression Profile Testing in Community Practice. J Clin Oncol 2018; 36:554-562. [PMID: 29309250 PMCID: PMC5815401 DOI: 10.1200/jco.2017.74.5034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Gene expression profile (GEP) testing can support chemotherapy decision making for patients with early-stage, estrogen receptor-positive, human epidermal growth factor 2-negative breast cancers. This study evaluated the cost effectiveness of one GEP test, Onco type DX (Genomic Health, Redwood City, CA), in community practice with test-eligible patients age 40 to 79 years. Methods A simulation model compared 25-year societal incremental costs and quality-adjusted life-years (QALYs) of community Onco type DX use from 2005 to 2012 versus usual care in the pretesting era (2000 to 2004). Inputs included Onco type DX and chemotherapy data from an integrated health care system and national and published data on Onco type DX accuracy, chemotherapy effectiveness, utilities, survival and recurrence, and Medicare and patient costs. Sensitivity analyses varied individual parameters; results were also estimated for ideal conditions (ie, 100% testing and adherence to test-suggested treatment, perfect test accuracy, considering test effects on reassurance or worry, and lowest costs). Results Twenty-four percent of test-eligible patients had Onco type DX testing. Testing was higher in younger patients and patients with stage I disease ( v stage IIA), and 75.3% and 10.2% of patients with high and low recurrence risk scores received chemotherapy, respectively. The cost-effectiveness ratio for testing ( v usual care) was $188,125 per QALY. Considering test effects on worry versus reassurance decreased the cost-effectiveness ratio to $58,431 per QALY. With perfect test accuracy, the cost-effectiveness ratio was $28,947 per QALY, and under ideal conditions, it was $39,496 per QALY. Conclusion GEP testing is likely to have a high cost-effectiveness ratio on the basis of community practice patterns. However, realistic variations in assumptions about key variables could result in GEP testing having cost-effectiveness ratios in the range of other accepted interventions. The differences in cost-effectiveness ratios on the basis of community versus ideal conditions underscore the importance of considering real-world implementation when assessing the new technology.
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Affiliation(s)
- Young Chandler
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Clyde B. Schechter
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jinani Jayasekera
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aimee Near
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suzanne C. O’Neill
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudine Isaacs
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles E. Phelps
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - G. Thomas Ray
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tracy A. Lieu
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott Ramsey
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeanne S. Mandelblatt
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
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Estimating progression-free survival in patients with glioblastoma using routinely collected data. J Neurooncol 2017; 135:621-627. [PMID: 28956223 PMCID: PMC5700233 DOI: 10.1007/s11060-017-2619-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 08/20/2017] [Indexed: 01/06/2023]
Abstract
Glioblastoma (GBM) represents 80% of all primary malignant brain tumours in adults. Prognosis is poor, and there is a clear correlation between disease progression and deterioration in functional status. In this pilot study we assess whether we can estimate disease progression and progression free survival (PFS) from routinely collected electronic healthcare data. We identified fifty patients with glioblastoma who had chemo-radiotherapy. For each patient we manually collected a reference data set recording demographics, surgery, radiotherapy, chemotherapy, follow-up and death. We also obtained an electronic routine data set for each patient by combining local data on chemotherapy/radiotherapy and hospital admissions. We calculated overall survival (OS) and PFS using the reference data set, and estimated them using the routine data sets using two different methods, and compared the estimated measures with the reference measures. Overall survival was 68% at 1 year and median OS was 12.8 months. The routine data correctly identified progressive disease in 37 of 40 patients and stable disease in 7 of 10 patients. PFS was 7.4 months and the estimated PFS using routine data was 9.1 and 7.8 months with methods 1 and 2 respectively. There was acceptable agreement between reference and routine data in 49 of 50 patients for OS and 35 of 50 patients for PFS. The event of progression, subsequent treatment and OS are well estimated using our approach, but PFS estimation is less accurate. Our approach could refine our understanding of the disease course and allow us to report PFS, OS and treatment nationally.
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Breast cancer neoplastic seeding in the setting of image-guided needle biopsies of the breast. Breast Cancer Res Treat 2017; 166:29-39. [PMID: 28730339 DOI: 10.1007/s10549-017-4401-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/13/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify clinicopathologic, technical, and imaging features associated with neoplastic seeding (NS) following image-guided needle breast biopsy. METHODS We performed an institutional review board-approved retrospective review of patients presenting with a new diagnosis of breast cancer or suspicious breast findings requiring biopsy with subsequent diagnosis of NS. The time from biopsy to NS diagnosis was calculated. Histology, grade, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, T category, and N category were recorded. Biopsy guidance method, needle gauge, and number of passes were reviewed in addition to the mammographic and sonographic features of the primary tumors and the NS. RESULTS Eight cases of NS were identified in 4010 patients. The mean time from biopsy to NS diagnosis was 60.8 days. The most frequent histology was invasive ductal carcinoma (7/8). Six cases were grade 3 (75.0%). Five primary breast cancers were ER, PR, and HER2 negative (62.5%). Seven patients underwent biopsy with ultrasound guidance. Multiple-insertion, non-coaxial ultrasound-guided core-needle biopsy was done in 6 cases. Mammographic presentation of NS was focal asymmetry (3/7 cases), mass (1/7), calcifications only (1/7), or occult (2/7). Sonographic presentation of NS was most often a mass (7/8) with irregular shape (5/7) and without circumscribed margins (6/7) and was occult in 1 case (1/8). NS distribution was subdermal and intradermal. CONCLUSION High-grade, triple-negative breast cancers and multiple-insertion, non-coaxial biopsies may be risk factors for NS. NS should be suspected on the basis of the superficial and linear pattern of disease progression in these patients.
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Sensitivity of Medicare Claims to Identify Cancer Recurrence in Elderly Colorectal and Breast Cancer Patients. Med Care 2017; 54:e47-54. [PMID: 24374419 DOI: 10.1097/mlr.0000000000000058] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Researchers are increasingly interested in using observational data to evaluate cancer outcomes following treatment, including cancer recurrence and disease-free survival. Because population-based cancer registries do not collect recurrence data, recurrence is often imputed from health claims, primarily by identifying later cancer treatments after initial treatment. The validity of this approach has not been established. RESEARCH DESIGN We used the linked Surveillance, Epidemiology, and End Results-Medicare data to assess the sensitivity of Medicare claims for cancer recurrence in patients very likely to have had a recurrence. We selected newly diagnosed stage II/III colorectal (n=6910) and female breast cancer (n=3826) patients during 1994-2003 who received initial cancer surgery, had a treatment break, and then died from cancer in 1994-2008. We reviewed all claims from the treatment break until death for indicators of recurrence. We focused on additional cancer treatment (surgery, chemotherapy, radiation therapy) as the primary indicator, and used multivariate logistic regression analysis to evaluate patient factors associated with additional treatment. We also assessed metastasis diagnoses and end-of-life care as recurrence indicators. RESULTS Additional treatment was the first indicator of recurrence for 38.8% of colorectal patients and 35.2% of breast cancer patients. Patients aged 70 and older were less likely to have additional treatment (P < 0.05), in adjusted analyses. Over 20% of patients either had no recurrence indicator before death or had end-of-life care as their first indicator. CONCLUSIONS Identifying recurrence through additional cancer treatment in Medicare claims will miss a large percentage of patients with recurrences; particularly those who are older.
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Neuman HB, Schumacher JR, Schneider DF, Winslow ER, Busch RA, Tucholka JL, Smith MA, Greenberg CC. Variation in the Types of Providers Participating in Breast Cancer Follow-Up Care: A SEER-Medicare Analysis. Ann Surg Oncol 2017; 24:683-691. [PMID: 27709403 PMCID: PMC5421989 DOI: 10.1245/s10434-016-5611-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers. METHODS Stages 1-3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care. RESULTS Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year). CONCLUSIONS Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers' responsibilities during follow-up care could lead to improved efficiency and quality of care.
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Affiliation(s)
- Heather B Neuman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Jessica R Schumacher
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David F Schneider
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Emily R Winslow
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rebecca A Busch
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer L Tucholka
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Maureen A Smith
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Population Health Sciences, UW Madison School of Medicine and Public Health, Madison, WI, USA
- Department of Family Medicine, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Whole breast irradiation vs. APBI using multicatheter brachytherapy in early breast cancer - simulation of treatment costs based on phase 3 trial data. J Contemp Brachytherapy 2016; 8:505-511. [PMID: 28115956 PMCID: PMC5241384 DOI: 10.5114/jcb.2016.64919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/19/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE A recent large phase 3 trial demonstrated that the efficacy of accelerated partial-breast irradiation (APBI) in the treatment of early breast cancer is non-inferior to that of whole breast irradiation (WBI) commonly used in this indication. The aim of this study was to compare the costs of treatment with APBI and WBI in a population of patients after conserving surgery for early breast cancer, and to verify if the use of APBI can result in direct savings of a public payer. MATERIAL AND METHODS The hereby presented cost analysis was based on the results of GEC-ESTRO trial. Expenditures for identified cost centers were estimated on the basis of reimbursement data for the public payer. After determining the average cost of early breast cancer treatment with APBI and WBI over a 5-year period, the variance in this parameter resulting from fluctuations in the price per single procedure was examined on univariate sensitivity analysis. Then, incremental cost-effectiveness ratio (ICER) was calculated to verify the cost against clinical outcome. Finally, a simulation of public payer's expenditures for the treatment of early breast cancer with APBI and WBI in 2013 and 2025 has been conducted. RESULTS The average cost of treatment with APBI is lower than for WBI, even assuming a potential increase in the unit price of the former procedure. There was no additional health benefit of WBI and the calculation of cost-effectiveness was based on the absolute difference in overall local control rate. However, this difference (0.92% vs. 1.44%) was fairly minimal and was not identified as statistically significant during 5 years. CONCLUSIONS The use of APBI as an alternative to WBI in the treatment of early breast cancer would substantially reduce healthcare expenditures in both 2013 and 2025, even assuming an increase in the price per single APBI procedure.
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Kemp-Casey A, Roughead EE, Saunders C, Boyle F, Bulsara M, Preen DB. Switching between endocrine therapies for primary breast cancer: Frequency and timing in Australian clinical practice. Asia Pac J Clin Oncol 2016; 13:e161-e170. [PMID: 27739214 DOI: 10.1111/ajco.12600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/01/2015] [Accepted: 01/03/2016] [Indexed: 12/16/2022]
Abstract
AIMS To determine the frequency, timing and patterns of endocrine therapy switching in Australian practice for postmenopausal women with primary breast cancer. METHODS We identified postmenopausal women in a population-based cohort commencing endocrine therapy for invasive primary breast cancer between December 2005 and December 2008 (n = 645). Individual-level administrative health records and self-report data were used to determine women's demographic and clinical characteristics, including preexisting and newly-treated comorbidities, and switches in endocrine therapy. Time to therapy switching was calculated. Chi-square tests compared the characteristics of women who did and did not switch, and those switching within 2 years or after 2 years of commencing therapy. RESULTS Twenty-eight percent of women switched from their initial endocrine therapy, most commonly from tamoxifen to anastrozole, or the converse. A small number of anastrozole-to-exemestane and letrozole-to-exemestane switches were observed (n = 19). Most women (>80%) who switched therapies did not have newly-treated comorbidities. Few women (<5%) switched before completing 2 years of therapy, but these women were significantly more likely to have preexisting antidepressant use than women switching later (43% vs 23%, P = 0.048) and remained on the subsequent therapy for less time (6 months vs 2.7 years, P < 0.001). CONCLUSIONS Approximately one-quarter of postmenopausal women with primary breast cancer switched endocrine therapies. The findings suggest that the majority of switching in Australian practice was planned; occurring after 2-3 years of, not precipitated by comorbidity, and in a sequence supported by trial evidence. Early switching, however, was associated with preexisting depression and appeared to be a marker of poor persistence.
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Affiliation(s)
- Anna Kemp-Casey
- University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia.,Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Christobel Saunders
- University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia
| | - Frances Boyle
- Patricia Richie Centre for Cancer Care and Research, The Mater Hospital and University of Sydney, Rocklands Road, Sydney, NSW, 2060, Australia
| | - Max Bulsara
- Institute of Health Research, University of Notre Dame, PO Box 1225, Fremantle, WA, 6959, Australia
| | - David B Preen
- University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia
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Neuman HB, Rathouz PJ, Winslow E, Weiss JM, LoConte NK, Lin CP, Wurm M, Smith MA, Schrag D, Greenberg CC. Use of a novel statistical technique to examine the delivery of breast cancer follow-up care by different types of oncology providers. J Eval Clin Pract 2016; 22:737-44. [PMID: 26991311 PMCID: PMC5026853 DOI: 10.1111/jep.12529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Frequent follow-up is recommended for the more than 3 million breast cancer survivors living in the USA. Given the multidisciplinary nature of breast cancer treatment, follow-up may be provided by medical oncologists, radiation oncologists, surgeons and primary care providers. This creates the potential for significant redundancy as well as gaps in care. The objective was to examine patterns of breast cancer follow-up provided by different types of oncologists and develop a statistical means of quantifying visit distribution over time. METHODS We identified stage I-III breast cancer patients who underwent breast conservation from 2000 to 2006 (n = 12 139) within the SEER-Medicare linked database. Provider type was defined using Medicare specialty provider codes and AMA Masterfile. The coefficient of variation (CV) for time between oncologist follow-up visits was calculated. Ordinal logistic regression assessed factors associated with CV. RESULTS Substantial variation in CV was observed. Sixty-seven per cent of patients with low CV (high visit regularity) received follow-up from a single oncologist type, versus 8% with high CV (low visit regularity). The number of oncologist types participating in follow-up had the greatest association with high CV (odds ratio 7.4 [6.7-8.3] and 15.4 [13.6-17.6] for two and three oncologist types). CONCLUSIONS Using a novel means of quantifying follow-up visit regularity, we determined that breast cancer patients with dispersed follow-up with more than one oncologist have more disordered care. The CV could be used in electronic medical records to identify cancer survivors with more disordered.
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Affiliation(s)
- Heather B Neuman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, UW Madison School of Medicine and Public Health, Madison, WI, USA.
- University of Wisconsin Carbone Cancer Center, UW Madison School of Medicine and Public Health, Madison, WI, USA.
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Emily Winslow
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer M Weiss
- University of Wisconsin Carbone Cancer Center, UW Madison School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Noelle K LoConte
- University of Wisconsin Carbone Cancer Center, UW Madison School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, Division of Hematology and Oncology, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Chee Paul Lin
- Center for Clinical and Translational Science, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mike Wurm
- Department of Biostatistics and Medical Informatics, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Maureen A Smith
- University of Wisconsin Carbone Cancer Center, UW Madison School of Medicine and Public Health, Madison, WI, USA
- Department of Population Health Sciences, UW Madison School of Medicine and Public Health, Madison, WI, USA
- Department of Family Medicine, UW Madison School of Medicine and Public Health, Madison, WI, USA
| | - Deborah Schrag
- Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, UW Madison School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin Carbone Cancer Center, UW Madison School of Medicine and Public Health, Madison, WI, USA
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Picot J, Copley V, Colquitt JL, Kalita N, Hartwell D, Bryant J. The INTRABEAM® Photon Radiotherapy System for the adjuvant treatment of early breast cancer: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-190. [PMID: 26323045 DOI: 10.3310/hta19690] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Initial treatment for early breast cancer is usually either breast-conserving surgery (BCS) or mastectomy. After BCS, whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A potential alternative to post-operative WB-EBRT is intraoperative radiation therapy delivered by the INTRABEAM(®) Photon Radiotherapy System (Carl Zeiss, Oberkochen, Germany) to the tissue adjacent to the resection cavity at the time of surgery. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of INTRABEAM for the adjuvant treatment of early breast cancer during surgical removal of the tumour. DATA SOURCES Electronic bibliographic databases, including MEDLINE, EMBASE and The Cochrane Library, were searched from inception to March 2014 for English-language articles. Bibliographies of articles, systematic reviews, clinical guidelines and the manufacturer's submission were also searched. The advisory group was contacted to identify additional evidence. METHODS Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were conducted. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to full texts of retrieved papers by one reviewer and checked by a second reviewer. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, and differences in opinion were resolved through discussion at each stage. Clinical effectiveness studies were included if they were carried out in patients with early operable breast cancer. The intervention was the INTRABEAM system, which was compared with WB-EBRT, and study designs were randomised controlled trials (RCTs). Controlled clinical trials could be considered if data from available RCTs were incomplete (e.g. absence of data on outcomes of interest). A cost-utility decision-analytic model was developed to estimate the costs, benefits and cost-effectiveness of INTRABEAM compared with WB-EBRT for early operable breast cancer. RESULTS One non-inferiority RCT, TARGeted Intraoperative radioTherapy Alone (TARGIT-A), met the inclusion criteria for the review. The review found that local recurrence was slightly higher following INTRABEAM than WB-EBRT, but the difference did not exceed the 2.5% non-inferiority margin providing INTRABEAM was given at the same time as BCS. Overall survival was similar with both treatments. Statistically significant differences in complications were found for the occurrence of wound seroma requiring more than three aspirations (more frequent in the INTRABEAM group) and for a Radiation Therapy Oncology Group toxicity score of grade 3 or 4 (less frequent in the INTRABEAM group). Cost-effectiveness base-case analysis indicates that INTRABEAM is less expensive but also less effective than WB-EBRT because it is associated with lower total costs but fewer total quality-adjusted life-years gained. However, sensitivity analyses identified four model parameters that can cause a switch in the treatment option that is considered cost-effective. LIMITATIONS The base-case result from the model is subject to uncertainty because the disease progression parameters are largely drawn from the single available RCT. The RCT median follow-up of 2 years 5 months may be inadequate, particularly as the number of participants with local recurrence is low. The model is particularly sensitive to this parameter. CONCLUSIONS AND IMPLICATIONS A significant investment in INTRABEAM equipment and staff training (clinical and non-clinical) would be required to make this technology available across the NHS. Longer-term follow-up data from the TARGIT-A trial and analysis of registry data are required as results are currently based on a small number of events and economic modelling results are uncertain. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006720. FUNDING The National Institute for Health Research Health Technology Assessment programme. Note that the economic model associated with this document is protected by intellectual property rights, which are owned by the University of Southampton. Anyone wishing to modify, adapt, translate, reverse engineer, decompile, dismantle or create derivative work based on the economic model must first seek the agreement of the property owners.
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Affiliation(s)
- Jo Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Vicky Copley
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jill L Colquitt
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Neelam Kalita
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Debbie Hartwell
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jackie Bryant
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Hurst RE, Bastian A, Bailey-Downs L, Ihnat MA. Targeting dormant micrometastases: rationale, evidence to date and clinical implications. Ther Adv Med Oncol 2016; 8:126-37. [PMID: 26929788 DOI: 10.1177/1758834015624277] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In spite of decades of research, cancer survival has increased only modestly. This is because most research is based on models of primary tumors. Slow recognition has begun that disseminated, dormant cancer cells (micrometastatic cells) that are generally resistant to chemotherapy are the culprits in recurrence, and until these are targeted effectively we can expect only slow progress in increasing overall survival from cancer. This paper reviews efforts to understand the mechanisms by which cancer cells can become dormant, and thereby identify potential targets and drugs either on the market or in clinical trials that purport to prevent metastasis. This review targets the most recent literature because several excellent reviews have covered the literature from more than two years ago. The paper also describes recent work in the authors' laboratories to develop a screening-based approach that does not require understanding of mechanisms of action or the molecular target. Success of this approach shows that targeting micrometastatic cells is definitely feasible.
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Affiliation(s)
- Robert E Hurst
- Oklahoma University Health Sciences Center, 105 BMSB, 940 SL Young Boulevard, Oklahoma City, OK 73104, USA
| | - Anja Bastian
- Physiology, College of Medicine, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | | | - Michael A Ihnat
- Department of Pharmaceutical Sciences, College of Pharmacy, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
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Zheng Z, Yabroff KR, Guy GP, Han X, Li C, Banegas MP, Ekwueme DU, Jemal A. Annual Medical Expenditure and Productivity Loss Among Colorectal, Female Breast, and Prostate Cancer Survivors in the United States. J Natl Cancer Inst 2015; 108:djv382. [PMID: 26705361 DOI: 10.1093/jnci/djv382] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There are limited nationally representative estimates of the annual economic burden among survivors of the three most prevalent cancers (colorectal, female breast, and prostate) in both nonelderly and elderly populations in the United States. METHODS The 2008 to 2012 Medical Expenditure Panel Survey data were used to identify colorectal (n = 540), female breast (n = 1568), and prostate (n = 1170) cancer survivors and individuals without a cancer history (n = 109 423). Excess economic burden attributable to cancer included per-person excess annual medical expenditures and productivity losses (employment disability, missed work days, and days stayed in bed). All analyses were stratified by cancer site and age (nonelderly: 18-64 years vs elderly: ≥ 65 years). Multivariable analyses controlled for age, sex, race/ethnicity, marital status, education, number of comorbidities, and geographic region. All statistical tests were two-sided. RESULTS Compared with individuals without a cancer history, cancer survivors experienced annual excess medical expenditures (for the nonelderly population, colorectal: $8647, 95% confidence interval [CI] = $4932 to $13 974, P < .001; breast: $5119, 95% CI = $3439 to $7158, P < .001; prostate: $3586, 95% CI = $1792 to $6076, P < .001; for the elderly population, colorectal: $4913, 95% CI = $2768 to $7470, P < .001; breast: $2288, 95% CI = $814 to $3995, P = .002; prostate: $3524, 95% CI = $1539 to $5909, P < .001). Nonelderly colorectal and breast cancer survivors experienced statistically significant annual excess employment disability (13.6%, P < .001, and 4.8%, P = .001) and productivity loss at work (7.2 days, P < .001, and 3.3 days, P = .002) and at home (4.5 days, P < .001, and 3.3 days, P = .003). In contrast, elderly survivors of all three cancer sites had comparable productivity losses as those without a cancer history. CONCLUSIONS Colorectal, breast, and prostate cancer survivors experienced statistically significantly higher economic burden compared with individuals without a cancer history; however, excess economic burden varies by cancer site and age. Targeted efforts will be important in reducing the economic burden of colorectal, breast, and prostate cancer.
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Affiliation(s)
- Zhiyuan Zheng
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - K Robin Yabroff
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Gery P Guy
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Xuesong Han
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Chunyu Li
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Matthew P Banegas
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Donatus U Ekwueme
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
| | - Ahmedin Jemal
- Affiliations of authors:Surveillance and Health Services Research Program, American Cancer Society , Atlanta, GA (ZZ, XH, AJ); Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD (KRY); Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA (GPGJr, CL, DUE); The Center for Health Research, Kaiser Permanente , Portland, OR (MPB)
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A Review of the Use of Medicare Claims Data in Plastic Surgery Outcomes Research. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e530. [PMID: 26579336 PMCID: PMC4634167 DOI: 10.1097/gox.0000000000000497] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/27/2015] [Indexed: 12/17/2022]
Abstract
With a growing national emphasis in data transparency and reporting of public health data, it is essential for researchers to know more about Medicare claims data, the largest and most reliable source of health-care utilization and expenditure for individuals older than 65 years in the United States. This article provides an overview of Medicare claims data for plastic surgery outcomes research. We highlight essential information on various files included in Medicare claims data, strengths and limitations of the data, and ways to expand the use of existing data for research purposes. As of now, Medicare data are limited in providing adequate information regarding severity of diagnosed conditions, health status of individuals, and health outcomes after certain procedures. However, the data contain all health-care utilization and expenditures for services that are covered by Medicare Parts A, B, and D (inpatient, outpatient, ambulatory-based and physician-based services, and prescription drugs). Additionally, Medicare claims data can be used for longitudinal analysis of variations in utilization and cost of health-care services at the patient level and provider level. Linking Medicare claims data with other national databases and utilizing the ICD-10 coding system would further expand the use of these datasets in health services research.
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DaCosta Byfield S, Buck PO, Blauer-Peterson C, Poston SA, DaCosta Byfield S, Buck PO, Blauer-Peterson C, Poston SA. ReCAP: Treatment Patterns and Cost of Care Associated With Initial Therapy Among Patients Diagnosed With Operable Early-Stage Human Epidermal Growth Factor Receptor 2-Overexpressed Breast Cancer in the United States: A Real-World Retrospective Study. J Oncol Pract 2015; 12:159-67. [PMID: 26395563 DOI: 10.1200/jop.2015.004747] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Overexpression of the human epidermal growth factor receptor 2 (HER2) protein negatively affects survival in breast cancer. This study aimed to assess real-world treatment patterns and costs associated with resected nonmetastatic HER2-positive breast cancer in the United States. PATIENTS AND METHODS Commercially insured patients with HER2-positive breast cancer were identified from oncology registry data linked to a large US commercial administrative claims database. Treatment patterns and health care use and costs in the initial phase of care were examined. RESULTS Among the 915 patients who met the study criteria, 662 (72%) were hormone receptor (HR) positive, and 253 (28%) were HR negative. Overall, 72% (n = 662) of patients received HER2-targeted therapy (HR positive, 69% v HR negative, 80%; P < .01), specifically trastuzumab. The most common treatment regimens, regardless of HR status, were carboplatin, docetaxel, and trastuzumab (47% of patients) during neoadjuvant therapy and carboplatin, docetaxel, and trastuzumab ± hormone therapy (30% of patients) during adjuvant therapy. Overall unadjusted cost of treatment per patient per month (HR positive, $11,906 v HR negative, $14,367; P < .001) was mainly cancer related (HR positive, $10,513 v HR negative, $13,073; P < .001). Adjusted 12-month cost was $176,779 (HR positive, $167,088 v HR negative, $180,226; P > .05). CONCLUSION Although trastuzumab-based therapy is considered standard of care among patients with HER2-positive early-stage breast cancer, approximately 28% of these patients did not receive HER2-targeted therapy. Additional studies are warranted to examine whether patients who have not received targeted therapy are eligible for and would benefit from an HER2-targeted approach.
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Affiliation(s)
| | - Philip O Buck
- Optum, Eden Prairie, MN; and GlaxoSmithKline, Philadelphia, PA
| | | | - Sara A Poston
- Optum, Eden Prairie, MN; and GlaxoSmithKline, Philadelphia, PA
| | | | - Philip O Buck
- Optum, Eden Prairie, MN; and GlaxoSmithKline, Philadelphia, PA
| | | | - Sara A Poston
- Optum, Eden Prairie, MN; and GlaxoSmithKline, Philadelphia, PA
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Jabbari E, Sarvestani SK, Daneshian L, Moeinzadeh S. Optimum 3D Matrix Stiffness for Maintenance of Cancer Stem Cells Is Dependent on Tissue Origin of Cancer Cells. PLoS One 2015; 10:e0132377. [PMID: 26168187 PMCID: PMC4500566 DOI: 10.1371/journal.pone.0132377] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/13/2015] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The growth and expression of cancer stem cells (CSCs) depend on many factors in the tumor microenvironment. The objective of this work was to investigate the effect of cancer cells' tissue origin on the optimum matrix stiffness for CSC growth and marker expression in a model polyethylene glycol diacrylate (PEGDA) hydrogel without the interference of other factors in the microenvironment. METHODS Human MCF7 and MDA-MB-231 breast carcinoma, HCT116 colorectal and AGS gastric carcinoma, and U2OS osteosarcoma cells were used. The cells were encapsulated in PEGDA gels with compressive moduli in the 2-70 kPa range and optimized cell seeding density of 0.6x106 cells/mL. Micropatterning was used to optimize the growth of encapsulated cells with respect to average tumorsphere size. The CSC sub-population of the encapsulated cells was characterized by cell number, tumorsphere size and number density, and mRNA expression of CSC markers. RESULTS The optimum matrix stiffness for growth and marker expression of CSC sub-population of cancer cells was 5 kPa for breast MCF7 and MDA231, 25 kPa for colorectal HCT116 and gastric AGS, and 50 kPa for bone U2OS cells. Conjugation of a CD44 binding peptide to the gel stopped tumorsphere formation by cancer cells from different tissue origin. The expression of YAP/TAZ transcription factors by the encapsulated cancer cells was highest at the optimum stiffness indicating a link between the Hippo transducers and CSC growth. The optimum average tumorsphere size for CSC growth and marker expression was 50 μm. CONCLUSION The marker expression results suggest that the CSC sub-population of cancer cells resides within a niche with optimum stiffness which depends on the cancer cells' tissue origin.
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Affiliation(s)
- Esmaiel Jabbari
- Biomimetic Materials and Tissue Engineering Laboratory, Department of Chemical Engineering, University of South Carolina, Columbia, SC, 29208, United States of America
| | - Samaneh K. Sarvestani
- Biomimetic Materials and Tissue Engineering Laboratory, Department of Chemical Engineering, University of South Carolina, Columbia, SC, 29208, United States of America
| | - Leily Daneshian
- Biomimetic Materials and Tissue Engineering Laboratory, Department of Chemical Engineering, University of South Carolina, Columbia, SC, 29208, United States of America
| | - Seyedsina Moeinzadeh
- Biomimetic Materials and Tissue Engineering Laboratory, Department of Chemical Engineering, University of South Carolina, Columbia, SC, 29208, United States of America
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A hybrid approach to identify subsequent breast cancer using pathology and automated health information data. Med Care 2015; 53:380-5. [PMID: 25769058 DOI: 10.1097/mlr.0000000000000327] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Many cancer registries do not capture recurrence; thus, outcome studies have often relied on time-intensive and costly manual chart reviews. Our goal was to build an effective and efficient method to reduce the numbers of chart reviews when identifying subsequent breast cancer (BC) using pathology and electronic health records. We evaluated our methods in an independent sample. METHODS We developed methods for identifying subsequent BC (recurrence or second primary) using a cohort of 17,245 women diagnosed with early-stage BC from 2 health plans. We used a combination of information from pathology report reviews and an automated data algorithm to identify subsequent BC (for those lesions without pathologic confirmation). Test characteristics were determined for a developmental (N=175) and test (N=500) set. RESULTS Sensitivity and specificity of our hybrid approach were robust [96.7% (87.6%-99.4%) and 92.1% (85.1%-96.1%), respectively] in the developmental set. In the test set, the sensitivity, specificity, and negative predictive value were also high [96.9% (88.4%-99.5%), 92.4% (89.4%-94.6%), and 99.5% (98.0%-99.0%), respectively]. The positive predictive value was lower (65.6%, 55.2%-74.8%). Chart review was required for 10.9% of the 17,245 women; 2946 (17.0%) women developed subsequent BC over a 14-year period. The date of subsequent BC identified by the algorithm was concordant with full chart reviews. CONCLUSIONS We developed an efficient and effective hybrid approach that decreased the number of charts needed to be manually reviewed by approximately 90%, to determine subsequent BC occurrence and disease-free survival time.
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Zeichner SB, Ambros T, Zaravinos J, Montero AJ, Mahtani RL, Ahn ER, Mani A, Markward NJ, Vogel CL. Defining the survival benchmark for breast cancer patients with systemic relapse. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2015; 9:9-17. [PMID: 25922577 PMCID: PMC4401244 DOI: 10.4137/bcbcr.s23794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/10/2015] [Accepted: 02/12/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our original paper, published in 1992, reported a median overall survival after first relapse in breast cancer of 26 months. The current retrospective review concentrates more specifically on patients with first systemic relapse, recognizing that subsets of patients with local recurrence are potentially curable. METHODS Records of 5,168 patients from a largely breast-cancer-specific oncology practice were reviewed to identify breast cancer patients with their first relapse between 1996 and 2006 after primary treatment. There were 189 patients diagnosed with metastatic disease within 2 months of being seen by our therapeutic team and 101 patients diagnosed with metastatic disease greater than 2 months. The patients were divided in order to account for lead-time bias than could potentially confound the analysis of the latter 101 patients. RESULTS Median survival for our primary study population of 189 patients was 33 months. As expected, the median survival from first systemic relapse (MSFSR) for the 101 patients excluded because of the potential for lead-time bias was better at 46 months. Factors influencing prognosis included estrogen receptor (ER) status, disease-free interval (DFI), and dominant site of metastasis. Compared with our original series, even with elimination of local-regional recurrences in our present series, the median survival from first relapse has improved by 7 months over the past two decades. CONCLUSION The new benchmark for MSFSR approaches 3 years.
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Affiliation(s)
- Simon B Zeichner
- Department of Hematology and Oncology, Emory Winship Cancer Institute, Atlanta, GA, USA
| | - Tadeu Ambros
- Department of Hematology and Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - John Zaravinos
- Department of Medicine, SUNY Downstate Medical Center, New York, NY, USA
| | - Alberto J Montero
- Department of Solid Tumor Oncology, Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland, OH, USA
| | - Reshma L Mahtani
- Department of Hematology and Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Boca Raton, FL, USA
| | - Eugene R Ahn
- Cancer Treatment Centers of America at Midwestern Regional Medical Center, Zion, IL, USA
| | - Aruna Mani
- Memorial Breast Cancer Center, Memorial Healthcare System, Pembroke Pines, FL, USA
| | | | - Charles L Vogel
- Department of Hematology and Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Boca Raton, FL, USA
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Ricketts K, Williams M, Liu ZW, Gibson A. Automated estimation of disease recurrence in head and neck cancer using routine healthcare data. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2014; 117:412-424. [PMID: 25306243 DOI: 10.1016/j.cmpb.2014.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/04/2014] [Accepted: 08/28/2014] [Indexed: 06/04/2023]
Abstract
BACKGROUND Overall survival (OS) and progression free survival (PFS) are key outcome measures for head and neck cancer as they reflect treatment efficacy, and have implications for patients and health services. The UK has recently developed a series of national cancer audits which aim to estimate survival and recurrence by relying on institutions manually submitting interval data on patient status, a labour-intensive method. However, nationally, data are routinely collected on hospital admissions, surgery, radiotherapy and chemotherapy. We have developed a technique to automate the interpretation of these routine datasets, allowing us to derive patterns of treatment in head and neck cancer patients from routinely acquired data. METHODS We identified 122 patients with head and neck cancer and extracted treatment histories from hospital notes to provide a gold standard dataset. We obtained routinely collected local data on inpatient admission and procedures, chemotherapy and radiotherapy for these patients and analysed them with a computer algorithm which identified relevant time points and then calculated OS and PFS. We validated these by comparison with the gold standard dataset. The algorithm was then optimised to maximise correct identification of each timepoint, and minimise false identification of recurrence events. RESULTS Of the 122 patients, 82% had locally advanced disease. OS was 88% at 1 year and 77% at 2 years and PFS was 75% and 66% at 1 and 2 years. 40 patients developed recurrent disease. Our automated method provided an estimated OS of 87% and 77% and PFS of 87% and 78% at 1 and 2 years; 98% and 82% of patients showed good agreement between the automated technique and Gold standard dataset of OS and PFS respectively (ratio of Gold standard to routine intervals of between 0.8 and 1.2). The automated technique correctly assigned recurrence in 101 out of 122 (83%) of the patients: 21 of the 40 patients with recurrent disease were correctly identified, 19 were too unwell to receive further treatment and were missed. Of the 82 patients who did not develop a recurrence, 77 were correctly identified and 2 were incorrectly identified as having recurrent disease when they did not. CONCLUSIONS We have demonstrated that our algorithm can be used to automate the interpretation of routine datasets to extract survival information for this sample of patients. It currently underestimates recurrence rates due to many patients not being well-enough to be treated for recurrent disease. With some further optimisation, this technique could be extended to a national level, providing a new approach to measuring outcomes on a larger scale than is currently possible. This could have implications for healthcare provision and policy for a range of different disease types.
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Affiliation(s)
- K Ricketts
- Department of Medical Physics and Bioengineering, University College London, UK
| | - M Williams
- Radiotherapy Department, University College London Hospital, London, UK; Department of Clinical Oncology, Imperial College Healthcare Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
| | - Z-W Liu
- ENT Department, Whipps Cross University Hospital, Whipps Cross Road, Leytonstone, London E11 1NR, UK
| | - A Gibson
- Department of Medical Physics and Bioengineering, University College London, UK
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Frederix GWJ, Severens JL, Hövels AM, van Hasselt JGC, Hooiveld MJJ, Neven P, Raaijmakers JAM, Schellens JHM. Real world cost of human epidermal receptor 2-positive metastatic breast cancer patients: a longitudinal incidence-based observational costing study in the Netherlands and Belgium. Eur J Cancer Care (Engl) 2014; 24:340-54. [PMID: 25413216 DOI: 10.1111/ecc.12266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 12/01/2022]
Abstract
Currently, no country-specific metastatic breast cancer (MBC) observational costing data are available for the Netherlands and Belgium. Our aim is to describe country-specific resource use and costs of human epidermal receptor 2 (HER-2)-positive MBC in the Netherlands and Belgium, making use of real-world data. The eligibility period for patient selection was from April 2004 to April 2010. Inclusion and retrospective data collection begins at the time of first diagnosis of HER-2-positive MBC during the eligibility period and ends 24 months post-index diagnosis of MBC or at patient death. We identified 88 eligible patients in the Netherlands and 44 patients in Belgium. The total costs of medical treatment and other resource use utilisation per patient was €48,301 in the Netherlands and €37,431 in Belgium. Majority of costs was related to the use of trastuzumab in both countries, which was 50% of the total costs in the Netherlands and 56% in Belgium respectively. Our study provides estimates of resource use and costs for HER-2-positive MBC in the Netherlands and Belgium. We noticed various differences in resource use patterns between both countries demonstrating caution is needed when transferring cost estimates between countries.
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Affiliation(s)
- G W J Frederix
- Science Faculty, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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Validating billing/encounter codes as indicators of lung, colorectal, breast, and prostate cancer recurrence using 2 large contemporary cohorts. Med Care 2014; 52:e65-73. [PMID: 23222531 DOI: 10.1097/mlr.0b013e318277eb6f] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND A substantial proportion of cancer-related mortality is attributable to recurrent, not de novo metastatic disease, yet we know relatively little about these patients. To fill this gap, investigators often use administrative codes for secondary malignant neoplasm or chemotherapy to identify recurrent cases in population-based datasets. However, these algorithms have not been validated in large, contemporary, routine care cohorts. OBJECTIVE To evaluate the validity of secondary malignant neoplasm and chemotherapy codes as indicators of recurrence after definitive local therapy for stage I-III lung, colorectal, breast, and prostate cancer. RESEARCH DESIGN, SUBJECTS, AND MEASURES We assessed the sensitivity, specificity, and positive predictive value (PPV) of these codes 14 and 60 months after diagnosis using 2 administrative datasets linked with gold-standard recurrence status information: CanCORS/Medicare (diagnoses 2003-2005) and HMO/Cancer Research Network (diagnoses 2000-2005). RESULTS We identified 929 CanCORS/Medicare patients and 5298 HMO/CRN patients. Sensitivity, specificity, and PPV ranged widely depending on which codes were included and the type of cancer. For patients with lung, colorectal, and breast cancer, the combination of secondary malignant neoplasm and chemotherapy codes was the most sensitive (75%-85%); no code-set was highly sensitive and highly specific. For prostate cancer, no code-set offered even moderate sensitivity (≤ 19%). CONCLUSIONS Secondary malignant neoplasm and chemotherapy codes could not identify recurrent cancer without some risk of misclassification. Findings based on existing algorithms should be interpreted with caution. More work is needed to develop a valid algorithm that can be used to characterize outcomes and define patient cohorts for comparative effectiveness research studies.
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Lang K, Huang H, Sasane M, Paly VF, Hao Y, Menzin J. Survival, healthcare resource use and costs among stage IV ER + breast cancer patients not receiving HER2 targeted therapy: a retrospective analysis of linked SEER-Medicare data. BMC Health Serv Res 2014; 14:298. [PMID: 25008431 PMCID: PMC4097046 DOI: 10.1186/1472-6963-14-298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 06/30/2014] [Indexed: 12/25/2022] Open
Abstract
Background Few studies have evaluated survival, treatment, resource use, and costs among women with stage IV ER + breast cancer (BC) who did not receive HER2 targeted therapy. Methods Using linked Surveillance, Epidemiology, and End Results (SEER) and Medicare data from 2006-2009, women aged 66+ years with an incident diagnosis of stage IV ER + BC (index date) in 2007 and no HER2 targeted therapy were identified. A comparison cohort without cancer was created from the SEER 5% Medicare sample and matched 1:1 to the study cohort based on age, sex, and race. All patients had continuous enrollment for a 12-month baseline period prior to index and were followed until the end of the study window, disenrollment, or death, whichever came first. Resource utilization and costs (by place of service, reported per patient per month, PPPM) were compared across cohorts. Treatment patterns including receipt of surgery, radiation, chemotherapy, aromatase inhibitors (AI), and non-AI hormonal therapy were evaluated for study cohort patients with at least 2 months of follow-up. Kaplan-Meier survival analysis was also conducted. Results 325 women with stage IV ER + BC without HER2 targeted therapy were identified and matched to 325 women without cancer. Mean age was 77 years for both cohorts, with average follow-up of 18 months for study patients and 26 months for comparison patients. Compared to the comparison cohort, study patients had significantly higher mortality (60.3% versus 31.1%, P < 0.001), shorter survival (survival at 36 months 28% vs. 62%) and higher resource utilization across all settings except for oral prescription drugs. Total PPPM healthcare costs were also significantly higher among study patients ($7,271 vs. $1,778, P < 0.001). Approximately 57% of study patients with 2+ months of follow-up received chemotherapy and over 62% received an AI during follow-up. Within 4 months of cancer diagnosis, surgery and radiation were received by 39% and 32% of study patients, respectively. Conclusions We found significant excess clinical and economic burden among women with stage IV ER + breast cancer who did not receive HER2 targeted therapy. Future studies with more precise and recent data are warranted to confirm and extend these results.
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Chawla N, Yabroff KR, Mariotto A, McNeel TS, Schrag D, Warren JL. Limited validity of diagnosis codes in Medicare claims for identifying cancer metastases and inferring stage. Ann Epidemiol 2014; 24:666-72, 672.e1-2. [PMID: 25066409 DOI: 10.1016/j.annepidem.2014.06.099] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/02/2014] [Accepted: 06/17/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Researchers are using diagnosis codes from health claims to identify metastatic disease in cancer patients. The validity of this approach has not been established. METHODS We used the linked 2005-2007 Surveillance, Epidemiology and End Results (SEER)-Medicare data to assess the validity of metastasis codes at diagnosis from claims compared with stage reported by SEER cancer registries. The cohort included 80,052 incident breast, lung, and colorectal cancer patients aged 65 years and older. Using gold-standard SEER data, we evaluated sensitivity, specificity, positive predictive value, and negative predictive value of claims-based stage, survival by stage classification, and patient factors associated with stage misclassification using multivariable regression. RESULTS For patients with a registry report of distant metastatic cancer, the sensitivity, specificity, and positive predictive value of claims never simultaneously exceeded 80% for any cancer: lung (42.7%, 94.8%, and 88.1%), breast (51.0%, 98.3%, and 65.8%), and colorectal (72.8%, 93.8%, and 68.5%). Misclassification of stage from Medicare claims was significantly associated with inaccurate estimates of stage-specific survival (P < .001). In adjusted analysis, patients who were older, black, or living in low-income areas were more likely to have their stage misclassified in claims. CONCLUSIONS Diagnosis codes in Medicare claims have limited validity for inferring cancer stage and metastatic disease.
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Affiliation(s)
- Neetu Chawla
- Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD; Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD.
| | - K Robin Yabroff
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Angela Mariotto
- Data Modeling Branch, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | | | | | - Joan L Warren
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
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Kemp A, Preen DB, Saunders C, Boyle F, Bulsara M, Malacova E, Roughead EE. Early discontinuation of endocrine therapy for breast cancer: who is at risk in clinical practice? SPRINGERPLUS 2014; 3:282. [PMID: 24936397 PMCID: PMC4058005 DOI: 10.1186/2193-1801-3-282] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 05/22/2014] [Indexed: 11/10/2022]
Abstract
PURPOSE Despite evidence supporting at least five years of endocrine therapy for early breast cancer, many women discontinue therapy early. We investigated the impact of initial therapy type and specific comorbidities on discontinuation of endocrine therapy in clinical practice. METHODS We identified women in a population-based cohort with a diagnosis of early breast cancer and an incident dispensing of anastrozole, letrozole or tamoxifen from 2003-2008 (N = 1531). Pharmacy and health service data were used to determine therapy duration, treatment for pre-existing and post-initiation comorbidities (anxiety, depression, hot flashes, musculoskeletal pain, osteoporosis, vaginal atrophy), demographic and other clinical characteristics. Time to discontinuation of initial, and any, endocrine therapy was calculated. Cox regression determined the association of different characteristics on early discontinuation. RESULTS Initial endocrine therapy continued for a median of 2.2 years and any endocrine therapy for 4.8 years. Cumulative probability of discontinuing any therapy was 17% after one year and 58% by five years. Initial tamoxifen, pre-existing musculoskeletal pain and newly-treated anxiety predicted shorter initial therapy but not discontinuation of any therapy. Early discontinuation of any therapy was associated with newly-treated hot flashes (HR = 2.1, 95% CI = 1.3-3.3), not undergoing chemotherapy (HR = 1.4, 95% CI = 1.1-1.8) and not undergoing mastectomy (HR = 1.5, 95% CI = 1.2-1.8). CONCLUSIONS Less than half of women completed five years of endocrine therapy. Women at greatest risk of stopping any therapy early were those with newly-treated hot flashes, no initial chemotherapy, or no initial mastectomy. This suboptimal use means that the reductions in recurrence demonstrated in clinical trials may not be realised in practice.
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Affiliation(s)
- Anna Kemp
- Centre for Health Services Research, School of Population Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
| | - David B Preen
- Centre for Health Services Research, School of Population Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
| | - Frances Boyle
- Patricia Richie Centre for Cancer Care and Research, The Mater Hospital, University of Sydney, Rocklands Road, North Sydney, NSW 2060 Australia
| | - Max Bulsara
- Institute of Health and Rehabilitation Research, University of Notre Dame, PO Box 1225, Fremantle, WA 6959 Australia
| | - Eva Malacova
- Centre for Health Services Research, School of Population Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009 Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001 Australia
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In H, Bilimoria KY, Stewart AK, Wroblewski KE, Posner MC, Talamonti MS, Winchester DP. Cancer recurrence: an important but missing variable in national cancer registries. Ann Surg Oncol 2014; 21:1520-9. [PMID: 24504926 DOI: 10.1245/s10434-014-3516-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cancer recurrence is a critically important outcome to patients and providers. However, no publicly available cancer registry data contain recurrence information. The National Cancer Data Base (NCDB) collects recurrence data; however, this information is not provided to researchers because of completeness and accuracy concerns. Our objective was to examine completeness of cancer recurrence information in the NCDB. METHODS Stage I-III thyroid/colon/melanoma/pancreas/breast cancers diagnosed in 2002-2005 were identified. Recurrence status, recurrence type, and recurrence date were evaluated for data completeness. Patient, tumor, and hospital factors were examined using generalized linear mixed models. Pseudo-R (2) statistics estimated the relative contribution of patient and hospital factors. RESULTS Of 702,144 patients with thyroid/colon/melanoma/pancreas/breast cancers treated in 1405 hospitals, recurrence information was incomplete in 21.5/24.0/20.2/34.8/18.2 % of patients, respectively. On average, hospitals had incomplete recurrence information on 56.7-66.7 % of their patients. Patients with incomplete information had more comorbidities, a higher cancer stage, non-private insurance, and lived farther from the hospital. Hospitals with the poorest collection were larger tertiary hospitals serving higher-income patients. However, these patients and hospital factors explained less than 3 %, while unexplained hospital variation accounted for the largest part of the observed variation (%ΔR (2) = 84 %). CONCLUSIONS The majority of hospitals report incomplete recurrence information for more than half of their patients. The presence of incomplete recurrence information was largely dependent on undefined hospital factors, rather than patient or tumor characteristics. Attempts to improve cancer recurrence information should focus on hospital operational and process factors surrounding how the hospital tumor registries collect recurrence data.
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Affiliation(s)
- Haejin In
- Cancer Programs, American College of Surgeons, Chicago, IL, USA,
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Shah C, Badiyan S, Khwaja S, Shah H, Chitalia A, Nanavati A, Kundu N, Vaka V, Lanni TB, Vicini FA. Evaluating radiotherapy options in breast cancer: does intraoperative radiotherapy represent the most cost-efficacious option? Clin Breast Cancer 2013; 14:141-6. [PMID: 24291378 DOI: 10.1016/j.clbc.2013.10.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 10/06/2013] [Accepted: 10/23/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This study analyzed the cost-efficacy of intraoperative radiation therapy (IORT) compared with whole-breast irradiation (WBI) and accelerated partial-breast irradiation (APBI) for early-stage breast cancer. MATERIALS AND METHODS Data for this analysis came from 2 phase III trials: the TARGIT (Targeted Intraoperative Radiotherapy) trial and the ELIOT (Electron Intraoperative Radiotherapy) trial. Cost analyses included a cost-minimization analysis and an incremental cost-effectiveness ratio analysis including a quality-adjusted life-year (QALY) analysis. Cost analyses were performed comparing IORT with WBI delivered using 3-dimensional conformal radiotherapy (3D-CRT), APBI 3D-CRT, APBI delivered with intensity-modulated radiotherapy (IMRT), APBI single-lumen (SL), APBI multilumen (ML), and APBI interstitial (I). RESULTS Per 1000 patients treated, the cost savings with IORT were $3.6-$4.3 million, $1.6-$2.4 million, $3.6-$4.4 million, $7.5-$8.2 million, and $2.8-$3.6 million compared with WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I, respectively, with a cost decrement of $1.6-$2.4 million compared with APBI 3D-CRT based on data from the TARGIT trial. The costs per QALY for WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I compared with IORT were $47,990-$60,002; $17,335-$29,347; $49,019-$61,031; $108,162-$120,173; and $36,129-$48,141, respectively, based on data from the ELIOT trial. These results are consistent with APBI and WBI being cost-effective compared with IORT. CONCLUSION Based on cost-minimization analyses, IORT represents a potential cost savings in the management of early-stage breast cancer. However, absolute reimbursement is misleading, because when additional medical and nonmedical costs associated with IORT are factored in, WBI and APBI represent cost-effective modalities based on cost-per-QALY analyses. They remain the standard of care.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Summa Health System, Akron, OH.
| | - Shahed Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Shariq Khwaja
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Hardeepak Shah
- Department of Family Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Ami Chitalia
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
| | - Anish Nanavati
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
| | - Neilendu Kundu
- Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Vikram Vaka
- Department of Psychiatry, University of Florida, Gainesville, FL
| | - Thomas B Lanni
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI
| | - Frank A Vicini
- Michigan Healthcare Professionals/21st Century Oncology, Farmington Hills, MI
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